Provider Demographics
NPI:1417054602
Name:GIBSON, JACQUELYN WARD (OTR)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:WARD
Last Name:GIBSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:GUNTER
Mailing Address - State:TX
Mailing Address - Zip Code:75058-0247
Mailing Address - Country:US
Mailing Address - Phone:903-433-1401
Mailing Address - Fax:903-433-1398
Practice Address - Street 1:610 N 8TH ST
Practice Address - Street 2:SUITE 6
Practice Address - City:GUNTER
Practice Address - State:TX
Practice Address - Zip Code:75058-3586
Practice Address - Country:US
Practice Address - Phone:903-433-1401
Practice Address - Fax:903-433-1398
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T6773OtherBCBS OF TEXAS
TX8F4266Medicare PIN